Fill and Sign the Settlement Workers Compensation Form

ILLINOIS WORKERS’ COMPENSATION COMMISSION SETTLEMENT CONTRACT LUMP SUM PETITION AND ORDER A TTENTION . Please type or print. Answer all questions. File four copies of this form. Attach a recent medical report. Workers' Compensation Act Occupational Diseases Act Fatal case? No Yes Date of death             Case #       WC       Employee/Petitioner       v.       Setting       Employer/Respondent To resolve this dispute regarding the benefits due the petitioner under the Illinois Workers' Compensation or Occupational Diseases Act, we offer the following statements. We understand these statements are not binding if this contract is not approved.             Employee's name Street address City, State, Zip code             Employer's name Street address City, State, Zip code State Employee? Yes No Male Female Married Single # Dependents under age 18    Birthdate       Average weekly wage $       Date of accident       How did the accident occur?       What part of the body was affected?       What is the nature of the injury?       The employer was notified of the accident orally in writing Return-to-work date       Location of accident       Did the employee return to his or her regular job? Yes No If not, explain below and describe the type of work the employee is doing, the wage earned, and the current employer's name and address.       T EMPORARY T OTAL D ISABILITY B ENEFITS : Compensation was paid for       weeks at the rate of $       /week. The employee was temporarily totally disabled from       through       . M EDICAL E XPENSES : The employer has has not paid all medical bills. List unpaid bills in the space below.       P REVIOUS AGREEMENTS : Before the petitioner signed an Attorney Representation Agreement , the respondent or its agent offered in writing to pay the petitioner $       as compensation for the permanent disability caused by this injury. An arbitrator or commissioner of the Commission previously made an award on this case on       regarding TTD $       Permanent disability $       Medical expenses $       Other $       IC5 5/12 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084 T ERMS OF SETTLEMENT : Attach a recent medical report signed by the physician who examined or treated the employee.       Total amount of settlement $       Deduction: Attorney's fees $       Deduction: Medical reports, X-rays $       Deduction: Other (explain) $       Amount employee will receive $       P ETITIONER ' S SIGNATURE . Attention, petitioner. Do not sign this contract unless you understand all of the following statements. I have read this document, understand its terms, and sign this contract voluntarily. I believe it is in my best interests for the Commission to approve this contract. I understand that I can present this settlement contract to the Commission in person. I understand that by signing this contract, I am giving up the following rights: 1. My right to a trial before an arbitrator; 2. My right to appeal the arbitrator's decision to the Commission; 3. My right to any further medical treatment, at the employer's expense, for the results of this injury; 4. My right to any additional benefits if my condition worsens as a result of this injury. _________________________                   Signature of petitioner Name of petitioner (please print) Telephone number Date P ETITIONER ' S ATTORNEY . I attest that any fee petitions on file with the IWCC have been resolved. Based on the information reasonably available to me, I recommend this settlement contract be approved. _________________________________       Signature of attorney Date       Attorney’s name and IC code # (please print)       Firm name       Street address       City, State, Zip code             Telephone number E-mail address R ESPONDENT ' S ATTORNEY . I attest that any fee petitions on file with the IWCC have been resolved. The respondent agrees to this settlement and will pay the benefits to the petitioner or the petitioner's attorney, according to the terms of this contract, promptly after receiving a copy of the approved contract. _________________________________       Signature of attorney or agent Date       Attorney’s name and IC code # or agent (please print)       Firm name       Street address       City, State, Zip code             Telephone number E-mail address       Name of respondent's insurance or service company (please print) O RDER OF ARBITRATOR OR COMMISSIONER : H aving carefully reviewed the terms of this contract, in accordance with Section 9 of the Act, by my stamp I hereby approve this contract, order the respondent to promptly pay in a lump sum the total amount of settlement stated above, and dismiss this case. IC5 page 2